Welcome to episode six of the Project EDWARD 2023 podcast. With me, James Luckhurst. The title of the podcast is My Role in the Safe System, and for this week's conversation, I've made the journey to the North East to catch up with someone whose own role in the safe system really only comes into play when something catastrophic has happened.

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Nevertheless, it's a vital function requiring extensive legal investigate and critical thinking skills, as well as the ability to use logic and reasoning and to understand complex scientific data.

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I'm Derek Winter. I'm senior coroner for the City of Sunderland, and I'm one of the two deputy chief coroners of England and Wales to be a coroner. You need to have a five year legal qualification. So a solicitor, barrister, legal executive and you should have a reasonable amount of life experience as well. I came to this role as a solicitor, as senior partner in a local law firm with a background mainly of family practice and mental health law and after an open competition by the local authority who are responsible for appointing their local coroner, I was successful.

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Every year we have a one day medical training day, and newly appointed coroners have an induction training about the judicial role and how to be a coroner in that medicolegal world. So it is quite a complex process. We currently have 81 coroner areas in England and Wales. Some of those senior coroners who lead the service in each area are supported by a full time area coroner and most areas will have a number of assistant coroners who set about 20 to 25 days each year.

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I think before we go through the questions that I've come up with, it's the most obvious one I should ask straightaway. I suppose it's death and it must be a very testing career on a daily basis. It can be, but in all walks of life where there are difficult circumstances to deal with, you will be professional about it.

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You will have good support from your family and from your coroner team and from the coroners in the country who will provide welfare support. And the chief coroner in his tenure has made a point of addressing a coroner welfare. He conducted a tour of every coroner area in the past couple of years to make sure that coroners themselves were fine, that they were properly resourced because that can be an issue for some coroners, and I expect most coroners will know where to go for support if they are having difficulties.

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Many cases will touch coroners personally, and the best way of dealing with, in my view, is to recognize what's going on in court and for everyone to take time out. Just have a break and compose themselves. For most people coming to the Coroner's Court, it will be their only attendance at the Coroner's Court and we're very lucky in this area was supported by volunteers from the Coroner's court support service who over the years have expanded into a number of other coroner ways to meet the needs of the families mainly.

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But anybody attending called who encounters upset or distress can can turn to the the volunteers and who are hoping in the coming months locally to establish a team of bereavement nurses who will look after families and professionals, including coroners if they need professional help and guidance. What does a typical day look like for you? A typical day for me starts early in the morning with walking the dogs in whatever weather the north East may throw at us.

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It's a good time for me to gather my thoughts and to look at the death referrals that have come in overnight. Death referrals now come into a coroner's office through a portal system on our ITV, and reports come in from general practitioners, from police primarily, and from the hospitals. And they they complete a series of requests for information and documents can be downloaded through the portal, which would include things like an identification statement or some information about a deceased person.

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Walking the dogs. Gives me time to just think about what's what's coming overnight, because you will not have any idea as to the numbers or the circumstances of those deaths coming in. And you really have to orientate yourself before you start the journey to the office. During the pandemic, we would have a teams meeting of all of my I'm coroner team, coroners officer, my P.A. to discuss the the caseload ahead and its allocation and what we were going to do about and various death reports.

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Because with those death reports, decisions have to be taken as to whether it's the sort of death which was expected. It may be natural and a doctor could sign the death certificates in terms there may be other cases which warrant further inquiry. There may be other cases where the cause of death is genuinely not known. Maybe if a young person or a suspected drugs death, perhaps, and then a postmortem examination would be required in the past couple of years, I would say we're moving away from invasive postmortem examinations to seat scanning.

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It's more expensive, but it's less upsetting for families and faith groups, and it's available to all if it's an appropriate case for scanning to take place. Some cases come and be dealt with by scanning. So the the start of the day is essentially a triage about what will require urgent attention, what might weight, what information we need. And then I will give directions to my coroners officers about what's required.

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The cause of death is not known. It's a violent death. Or somebody dies in state detention. If a person has died as a consequence of a road traffic collision, there may be some reason for that. There may be an underlying health condition. There may be human error. There may be a raft of other circumstances. Influence saying what has happened, perhaps drugs or alcohol.

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So the coroner's involvement would usually come either through the police traffic investigation unit or possibly from the emergency department at the hospital. If somebody had been taken there and then the coroner's inquiry would would commence and we would make a decision about postmortem examination, whether by scanning or invasive techniques, we may inevitably take toxicology to look for alcohol or prescription or illicit drugs in somebody's system that may have played a part.

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The police will set about doing their inquiries, which will be a very thorough examination of the the scene of the collision. They will examine the vehicle, they will take witness statements, and all of that will take time from a very specialist unit. And there's a coroner. I have to wait for that to be presented to me with sometimes complex calculations and analysis of the mechanical parts of the vehicle.

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But in the meantime, what we're trying to establish is what is the cause of death and to make sure that we can get an early release of a deceased person back to their family so that they can have their funeral. And there may be criminal proceedings on on on the back of that road traffic collision, which may impact on my ability to deliver an early inquest hearing.

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Let's talk about the relationship between the families and the authorities that they will meet on the journey that they were never expecting to have to make but are thrown into it violently. Suddenly, probably the knock on the door in the middle of the night. Life changes forever. I guess that's something you've got in your mind when you meet them.

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We always have the family at the heart of the process. It's their loss. There may be confusion with with the system that they're about to be exposed to. We have a very informative website. We're very open and transparent about when our hearings are taking place. I'm very conscious that this is a state imposed system on families. They may not want the postmortem examination.

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To them, the cause of death may seem very obvious, but that might be their initial reaction because in the fullness of time they will want answers to more detailed questions. And I see it as my role to provide them with as many answers to their questions as I can provide and to minimize distress so the families may have a family liaison officer from the police, somebody that they've never had to deal with before.

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There will be that that informed message, which is an awful function for any police officer to have to deliver at all times of the day. And then when the case is referred to the coroner and my team will make contact very early on in the process with the family to guide them through. And my practice here in Sunderland is to make sure that the coroner's officer who picks up the case on the referral will stay with that family to the very end of the case when the inquest is concluded.

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And that's really important for continuity for the family so that they're not having to explain to different people at different times their story and what their expectations are. And I see it as my officer's role to manage the family's expectations that the coroner is there to determine who the person was, who's died when they died, where they died, and how they came about that death, and recalled the particulars required for a death certificate.

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And the coroner's court is is not into apportioning blame. We are directed by law that we cannot appear to determine civil liability or criminal liability on the part of the name person. Those matters are full of the courts. And one of the recent innovations that the chief coroner has pushed through is that an inquest the family should have the ability to tell us something about their loved one.

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They don't have to if that they don't want to. And some will do it in different ways. But it's it's called a pen portrait and there's chief coroner guidance on that very subject matter and how coroners should introduce an portrait of the person who's passed away so that we we recognize that we're dealing with a particular individual and the impact of their loss on the family.

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Maybe we can explore the relationship you have with partners, the police, pathologists, forensic scientists, explain what you need from each other and how it works. And like other judges, a coroner has to engage with many groups and you've touched upon many of those already. So pathology is provided in different ways and it's not part of a pathologist NHS work usually.

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So we're dealing with pathologists from the NHS setting in more difficult pathology cases. We're dealing with home office forensic pathologists, we are dealing with the science behind all of those individuals as well. So the laboratories for toxicology of the ologist, so they may be anthropologists, they may be old oncologists, that can be a lot of individuals that we need to engage with to tap into their expertise so that we get the answers to the questions that the families raised and as part of our investigation, to make sure we get the best information we can.

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We have to forge relationships, obviously, with our police, with our health trusts, with our paramedics. And it's important that we understand how one another will work, what our expectations are that if I said I require a statement in 14 days, that it arrives by the 14th and not the 15th day and that the information can be given to the families.

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So it's important that coroners engage in speaking events, do podcasts, do what they can to demystify the process and to make sure that there are good working relationships with all organizations, which are many, because every type of death will bring with it different organizations. So suicide would bring in the mental health trusts. A drug death will bring in our drug surveillance teams.

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There are lots of things that a coroner will be doing in the back office to make sure that there's good and effective service delivery. I'm sure not every postmortem is straightforward, so why can some take so long? And what happens if if a family or party that's connected with the case challenges the outcome post mortem examinations? There are about 90,000 or thereabouts in England and Wales every year from 600,000 deaths.

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And there are statistics published by the Ministry of Justice which are on the Internet which give out national statistics and more local statistics for each coroner area, including how many mortem examinations were carried out, whether they were invasive procedure or by scan. Sometimes a pathologist can do an examination and they will see something to the naked eye and they can clearly establish what the cause of death is.

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So that's a macro scoping examination. But on some occasions the cause of death is less clear. And there are times where the pathologist will need to take samples to look at down the microscope, and we call that histology. That can take time to to be prepared and to then examine and then try to report upon. There may be other tests where, for example, a brain might have to be examined by a neuropathologist.

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And again, that can take time. But the timescales to a large extent are determined by the cause of death or likely cause of death and the availability of pathologists and experts to help the coroner, because as I've said, it's all part of their NHS work. Very often they have to be paid privately. The statutory fee is currently by £96 for postmortem examination and most pathologists then have to make up that time to the NHS if they come away from their place of work to do this work for the coroner.

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There are other areas which can take a while to deliver a report and the pathologist will not just of course examine a body, but the pathologist will be reading through the case notes as well. They have other duties to attend to for baby and child deaths in this area. We have male pediatric pathologists in the area, so sadly, babies and young children have to go to either Leeds or Sheffield for examination.

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And that's distressing for families at a difficult time to know that their their baby is out of the area. But we try very hard to get funerals undertaken as swiftly as we can, but also to try and get reports delivered in a in a timely way because families need to know the reason for somebodies death. And and also one of the the collateral benefit of a postmortem examination can be that you can identify genetic conditions, inherited illnesses and direct people safer for screening through their GP.

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So it's a really important public health function that the coroner has, and I'm afraid pathology needs to be tackled so we can try and get reports soon in a in a better way for families. Let's just talk about the causes of of road collisions because everything points to it being mostly to do with human error. Does your experience back that up?

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Human error does account for a lot of road traffic collisions. Sometimes people are overly ambitious with their driving skills, their speed awareness, the consideration for their own safety, drugs and alcohol. Sadly, will have a significant impact on people's cognitive functioning. We do see road traffic collisions where there are no human factors directly involved, so a road layout may need to be considered or signage may be subject to scrutiny.

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There have been some inquests dealing with smart motorways, for example, in terms of their safety. So there are there are lots of different factors come to play when a coroner is doing an investigation. Speed is is probably the most significant factor in my view. Your job has many challenges, Derek, but what's what's on the on the positive side, what's rewarding and what do you gain from what you do?

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The most important thing is to help families through that crisis. And those families, in my view, if they come to an inquest, will say they don't want this to happen to somebody else. And that goes to another public health function that coroners fulfill. And that is the ability that, Judy, in fact, to write a report to prevent future deaths.

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If there are concerns apparent to the coroner, For example, during the inquest hearing and the rules on prevent future death, reports are very clear that if those concerns exist, the coroner's duty is to write a report to an organization mainly who can make a difference. And if a coroner sends a prevent Future death report to that organization, they're obliged to respond in 56 days that they can apply for an extension of time.

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But part of Open Justice is that reports are published on the Chief Coroner website and also the responses to those reports are published. And for people to see what reports coroners have written about systems that might have local or national interest. And it's it's very gratifying if if the coroner's investigation can resolve the problem and go on to save a life and then the families at least take something away from the inquest process, having had a catastrophe in their lives with their own loss.

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Derek Winter, Deputy Chief Coroner of England and Wales and His Majesty's Senior Coroner for the City of Sunderland. And that concludes this week's episode. Do you like us? Share us and encourage your colleagues and friends to download the podcast or to listen via the project? Edward Website. Next week we're in the company of Durham's police and crime Commissioner, Joy Allan with the National Police Chiefs Council lead for Roads Policing Jo Shiner.

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Do join us then. But for now, from me, James, like us for this week, it's goodbye.